If you have atrial fibrillation, your doctor may have spoken to you about the left atrial appendage occlusion procedure (LAAO). This procedure means that a cardiologist (heart doctor) will insert a device into your heart to prevent a stroke when in atrial fibrillation. The following will give you an overview of atrial fibrillation and stroke prevention, and how a LAAO may work for you. If you have more questions, talk to a member of your healthcare team.

Understanding your heart

The heart is divided into 4 parts called chambers. The 2 upper chambers of the heart are the right and left atria and the 2 bottoms chambers are the right and left ventricles.

The 4 chambers fill with blood when the heart is at rest and then pump blood through the body when the heart muscle contracts (shortens) with each heartbeat. The electrical system of the heart causes the heart muscle to contract and pump blood through the blood vessels.

After the heart pumps the blood, it rests and fills with new blood until the next contraction of the heart muscle.

What is atrial fibrillation and how is it treated?

In atrial fibrillation (AF), the right and left atria don’t contract at the same time as the ventricles so the heart beat (pulse) is abnormal (irregular).

AF is treated with medicine to prevent the heart beat from getting too fast. The medicine usually helps people feel better so they’re able to do everyday activities, even when they have AF.

Not everyone who takes medicine for AF, will feel better. If this happens, you will need more of the same medicine, another type of medicine, or a heart procedure such as cardioversion and ablation to try to stop AF and keep the heartbeat regular.

Cardioversion uses electricity or chemicals to make the heart beat normal.

Cardiac ablation uses heat or freezing to destroy the part of the heart that is causing AF.

Left atrial appendage occlusion (LAAO) is a procedure that prevents blood clots in the left atrial appendage related to AF from going into the blood stream and causing a stroke. It is used along with medicines or other procedures to treat AF.

Heart showing the left atrium and appendage
Source: Boston Scientific, 2015, Watchman Patient Guide

Atrial fibrillation and blood clots in the heart

The blood flow in the atria may be slower than normal when you have atrial fibrillation (AF). This can cause a blood clot (thromboembolus) to form.

A blood clot is a called a thrombus when it stays in one place. If it breaks loose and travels to another part of the body, it’s called a thromboembolus. A thromboembolus can be dangerous if it blocks a blood vessel that supplies blood to an important body part.

Blood clots related to AF that start in the heart most often develop in a pouch of the left atrium called the left atrial appendage (LAA).

If a blood clot leaves the LAA, it can travel to different parts of the body and get stuck in a blood vessel. This can block the flow of blood to organs and damage them. If a blood clot blocks a blood vessel in the brain, it can cause a stroke. The part of the brain that’s supplied by that blood vessel can become permanently damaged within minutes.

A stroke can cause loss of movement or feeling (sensation) in a part of the body, weakness, problems speaking, and even death.

How a blood clot gets to the brain

Source: Boston Scientific, 2015, Watchman Patient Guide

Not everyone with AF has the same risk for an LAA blood clot or stroke. You have a higher risk of an LAA blood clot or stroke if you:

• are over the age of 65
• have high blood pressure, heart failure, diabetes, or other heart disease
• have had a stroke (including a mini-stroke called a transient ischemic attack or TIA) or blood clot in the past

Atrial fibrillation and blood thinners

People with atrial fibrillation (AF) have a higher risk of stroke so they’re treated with medicines called blood thinners or anticoagulants that help prevent a stroke.

Most people can safely take a blood thinner for many years without any problems. But some people develop bleeding problems.

If this happens, bleeding problems are usually mild. But in some people, the bleeding can be bad enough that they have to be admitted to hospital and may even need a blood transfusion. In rare cases, bleeding can be life-threatening or cause death (from bleeding into the brain or stroke).

Blood thinners prevent strokes more often than they cause them. Your doctor will decide if a blood thinner is the best treatment for you.

For some people, the risk of serious bleeding is too high, so taking blood thinners isn’t the best treatment.

For these people, a left atrial appendage occlusion (LAAO) may be the best treatment.

If you’re doing well on your blood thinner treatment, and there’s no reason to think that you won’t keep doing well, LAAO is likely not the best treatment for you.

How does a doctor decide if LAAO is the best treatment for me?

When a person with atrial fibrillation (AF) develops a blood clot in the heart, it most often develops in the left atrial appendage (LAA). LAAO is a procedure that places a device that acts as a barrier to prevent blood clots in the left atrial appendage from going into the blood stream and causing a stroke.

LAAO won’t prevent other types of strokes that are caused by high blood pressure and narrowing of the blood vessels to the brain.

When deciding if LAAO is the best treatment for you, your doctor will look at your:

• overall risk of stroke
• risk of stroke caused by a blocked blood vessel in the brain
• risk of a major bleeding problem while taking a blood thinner (including bleeding in the brain)

When you have an LAAO device, you can still have magnetic resonance imaging (MRI) if you need it.

When is LAAO not the best treatment?

There are many reasons why LAAO may not be the best treatment, such as when you:

• already have a blood clot in the heart (the blood clot has to be treated before LAAO)
• have an LAA that is too big or too small for the LAAO device
• can’t take aspirin or clopidogrel (Plavix)
• can’t have a procedure that puts a long thin wire (called a catheter) in your heart
• are allergic or sensitive to nickel or titanium (types of metal)
• have a serious heart valve disease

You will need some tests before you can have an LAAO.

Transesophageal Echo

A transesophageal echo (TEE) is a type of ultrasound test that uses sound waves to look at the parts of the heart. TEE helps give clear images of the atrium that can’t be seen with regular ultrasound.

TEE is done by passing a tube (called an ultrasound probe) down your food pipe (esophagus). The procedure is done through the esophagus since it lies right behind the heart and makes it easier to see the left atrium.

You will have a TEE about 4 weeks before having an LAAO and again 6 weeks after.

Echocardiogram

An echocardiogram is another type of ultrasound that uses sound waves to look at the size of the heart and see how well the valves and the heart muscle are working. You will have an echocardiogram after the LAAO procedure, before you go home.

Echocardiogram

Source: Northside Heart Echocardiogram

Electrocardiogram (ECG)

An electrocardiogram is a test that checks for problems with the electrical activity of the heart.

Blood Tests

Blood tests check how well your kidneys are working and how many blood cells you have (called blood count).

Computerized Tomography (CT) Scan

A CT scan uses x-rays to take detailed images of the inside of the body. A CT scan helps to measure the size of the left atrial appendage. Sometimes a dye (called contrast) is injected into your body before the scan to look for a blood clot in your heart. A CT scan is done 3 to 4 weeks before LAAO.

LAAO is done by a doctor called an electrophysiologist. An electrophysiologist is a heart doctor (cardiologist) that treats abnormal heart rhythms. To do LAAO, the doctor puts a catheter (long, thin wire) into a blood vessel and passes it into the heart.

Most of the time, this procedure is done through a vein on the right side of the groin (called the femoral vein). In rare cases the procedure is done through veins on both sides of the groin. The doctor also injects a dye (contrast media) to help guide the device and make sure it fits well in the left atrial appendage (LAA).

When the catheter reaches the heart, it will go into the right atrium. The catheter will be passed from the right atrium to the left atrium by making a small hole in the wall (called the septum) between these 2 upper chambers of the heart.

The LAAO device is passed through the catheter into the LAA.

Implanted LAAO Device
Source : Boston Scientific, 2015, Watchman Patient Guide

The electrophysiologist makes sure that the device is in the right place within the LAA. They open the device that is tightly folded in the catheter, much like opening up a folded umbrella.

When the procedure is done, the catheter is removed and only the LAAO device stays in the body. LAAO takes 2 to 4 hours.

What are the risks of LAAO?

The main risks of LAAO include:

• bleeding or bruising where the catheter went in the groin
• damage to the femoral veins from the catheter – To lower your risk, rest in bed for a few hours after the procedure.
• clots within your heart or around the catheters – You will get a blood thinner during LAAO to lower this risk.
• damage or a tear to the heart muscle or valve
• a hole in the heart that causes blood to leak into the sac around it – This blood may be drained by placing a needle in the sac or in some cases open heart surgery is needed.

Only 1 or 2 out of 100 people having an LAAO will have a complication.

Getting ready for LAAO

Don’t eat or drink anything after midnight on the day before your procedure. Be at the hospital on time and go to the department where you’re having your procedure.

At the department you will:

• change into a gown
• get an IV (intravenous) in your arm
• meet with the doctor who will explain the procedure and answer your questions
• sign the consent form (once you understand the procedure and if you haven’t already signed one)

When the procedure is ready to begin, you will go to the electrophysiology (EP) Lab where you will:

• lie on a narrow bed
• get ECG electrodes and other patches will be put on your back and chest (these are taken off after the procedure)
• get a general anesthetic (sleeping medicine) to help you stay comfortable during the procedure
• get freezing or anesthetic to numb your groin where the catheter will be passed

After the LAAO

• When the procedure is done, the doctor will close the opening in the groin with a stitch. This stitch is taken out before you go home.
• You’ll go to the post-anesthetic care unit (also called the PACU or recovery room) right after the procedure. Once you wake up from the procedure, you’ll go to another unit of the hospital where you’ll lie flat for 3 hours to prevent bleeding.
• You’ll stay in the hospital overnight and go home in the morning.
• Before you leave the hospital, you’ll get an identification (ID) card that says you have an implanted device. Keep this ID card with you and show it anytime you see a doctor, dentist, or go to an emergency department.

When to go to the hospital

Go to an emergency department if you:

• have chest pain
• have trouble breathing
• are dizzy, feel like you may pass out, or if you’ve fainted

Don’t drive yourself if you don’t feel well. Have someone drive you or call 911.

If you go to the emergency department or see a doctor for any issues related to your LAAO procedure, please call the clinic the same day or the next day.